Mental health professionals have a 'duty to warn' about a leader who may be unfit to serve.

If you take President Trump’s words literally, you have no choice but to conclude that he is psychotic. A delusion is “a fixed false belief that is resistant to reason or confrontation with actual fact.” Despite all evidence to the contrary, Trump asserts that his New York office was bugged by President Obama, and that his inauguration had the biggest crowd size in history. Before the election, Right Wing Watch published a list of 58 conspiracies proclaimed by Trump.

Is it all for effect, to rile up his base, deflect blame and distract from his shortcomings, or does Trump really believe the insane things he says? It’s often hard to know, because as Harvard psychoanalyst Lance Dodes put it, Trump tells two kinds of lies: the ones he tells others to scam them, and those he tells himself. “He lies because of his sociopathic tendencies," Dodes said. "There's also the kind of lying he has that is in a way more serious, that he has a loose grip on reality." Is he crazy like a fox or just plain crazy? Not a question we want to be asking about our president.

Much has been written about Trump having narcissistic personality disorder. As critics have pointed out, merely saying a leader is narcissistic is hardly disqualifying. But malignant narcissism is like a malignant tumor: toxic.

Psychoanalyst and Holocaust survivor Erich Fromm, who invented the diagnosis of malignant narcissism, argues that it “lies on the borderline between sanity and insanity.” Otto Kernberg, a psychoanalyst specializing in borderline personalities, defined malignant narcissism as having four components: narcissism, paranoia, antisocial personality and sadism. Trump exhibits all four.

His narcissism is evident in his “grandiose sense of self-importance … without commensurate achievements.” From viewing cable news, he knows "more about ISIS than the generals” and believes that among all human beings on the planet, “I alone can fix it.” His "repeated lying," “disregard for and violation of the rights of others” (Trump University fraud and multiple sexual assault allegations) and “lack of remorse” meet the clinical criteria for anti-social personality. His bizarre conspiracy theories, false sense of victimization, and demonization of the press, minorities and anyone who opposes him are textbook paranoia. Like most sadists, Trump has been a bully since childhood, and his thousands of vicious tweets make him perhaps the most prolific cyber bully in history.

A year ago, I warned that “the idea that Trump is going to settle down and become presidential when he achieves power is wishful thinking.” Trump, like many successful people, shows biological signs of hypomania — a mild and more functional expression of bipolar genes that manifest in energy, confidence, creativity, little need for sleep, as well as arrogance, impulsivity, irritability and diminished judgment. As is often typical, when Trump has achieved great success, his hypomania has increased with disastrous consequences.

In Michael Kruse's article “1988: the Year Donald Lost his Mind,” he wrote, “His response to his surging celebrity” after the publication of The Art of The Deal “was a series of manic, ill-advised ventures” that led to bankruptcy and divorce.

Last year, after Trump became the Republican presidential nominee, New York Times columnist David Brooks noted a similar deterioration: “With each passing week, he displays the classic symptoms of medium-grade mania in more disturbing forms: inflated self-esteem, sleeplessness, impulsivity, aggression and a compulsion to offer advice on subjects he knows nothing about.” Much has been said about Trump's disjointed Associated Press interview last month. As Brooks wrote, “Manics display something called ‘flight of ideas.’ It's a formal thought disorder in which ideas tumble forth through a disordered chain of associations. One word sparks another, which sparks another …”

One symptom of hypomania is impulsivity. Seventy-two hours after Trump saw upsetting pictures of gassed Syrian children, he launched 59 Tomahawk missiles at the Assad regime. Whether Trump guessed right or wrong, sudden lethal moves that reverse his longstanding policy are disturbing. “Acting on instinct, Trump upends his own Syria policy” was the headline in The Times. Its analysis said the president’s advisers “were clearly uncomfortable with the suggestion that Mr. Trump was acting impulsively." As Ezra Klein put it, “A foreign policy based on Trump’s gut reactions to the images flashing before him on cable news” is “dangerous.”

Now Trump is ratcheting up tensions to create a crisis with North Korea.

Some say it is unethical to dare to diagnose the president, but hundreds of mental health professionals have come together to found Duty To Warn. We believe that just as we are ethically and legally obligated to break confidentiality to warn a potential victim of violence, our duty to warn the public trumps all other considerations.

More than 53,000 people have signed our petition, aimed at mental health professionals, stating Trump should be removed under the 25th Amendment because he is too mentally ill to competently serve. At a conference on the Duty To Warn last month at Yale medical school, psychiatrist Robert Jay Lifton warned against creeping “malignant normality.” Under a malignantly narcissistic leader, alternate facts, conspiracy theories, racism, science denial and delegitimization of the press become not only acceptable but also the new normal. If we do not confront this evil, it will consume us.

Duty to Warn is planning a multicity March for Sanity on Oct. 7 to “make America sane again.” Hope to see you there, assuming we’re all still here.

Psychologist John Gartner, the founder of Duty To Warn, taught in the Department of Psychiatry at Johns Hopkins University School of Medicine for 28 years. He is the author of In Search of Bill Clinton: A Psychological Biography.